Appointment Request Form

Appointment Request Form
Today's Date: *

MonthDayYear
Legal Name: *

First NameLast Name
Client Date of Birth: *

MonthDayYear
Date
Sex:*
Parent/Legal Guardians Name (If Applicable):

First NameLast Name
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number:*
Email*
example@example.com
Are you able to receive texts at the phone number provided?*

YESNO
How were you referred to our office?*

Previous ClientInsurance CompanyPrimary Care ProviderEmployee Assistance ProgramChild Protective ServicesAttorneyFamily/FriendOther
Primary Care Provider:
Please select the appropriate reason for referral. In the section below, please provide greater detail.*

CounselingMedication ManagementPsychological or Neuropsychological Testing
Please provide a brief reason for coming in below. This assists us in setting you up with a clinician that will meet your needs.
Do you have a provider in mind? If not, please list whether you prefer a male or female therapist or no preference.
In the past year have you thought of harming yourself or others?*

YESNO
If yes, and this is an urgent issue. You may reach out to the 24/7 crisis line by calling or texting 988 or calling 911 if this is an emergency.

If this is an emergency, please do not wait for our office to contact you, seek help immediately.
Insurance Information

If you are utilizing your insurance benefits, the section below is required.
Insurance Company Name:
Subscriber ID #:
Group #:
Customer Service Phone #:
Subscriber's Name:

First NameLast Name
Subscriber's Date of Birth:

MonthDayYear
Date
Subscriber's Employer:
Please upload an image of the front & back of your insurance card(s):

Cancelof
Secondary Insurance Information

If applicable, please complete secondary insurance information. This section is required if you intend to use secondary insurance benefits.
Secondary Insurance Company Name:
Secondary Subscriber ID#:
Secondary Group #:
Customer Service Phone Number:
Secondary Insurance Subscribers Name:

First NameLast Name
Secondary Insurance Subscriber's Date of Birth:

MonthDayYear
Date
Secondary Insurance Subscriber's Employer:
Office Use Only
Should be Empty:

Appointment Request Form

If yes, and this is an urgent issue. You may reach out to the 24/7 crisis line by calling or texting 988 or calling 911 if this is an emergency.

Insurance Information

Secondary Insurance Information

Office Use Only